In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To prepare:

• By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
• Review the following case studies:

Case 1: Back Pain

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

 

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Please, the assignment needs to be in Episodic/Focused format, so I have attached the Episodic/Focused SOAP Note format. However, you just complete these four sections below

• HPI (History of present illness)
• OBJECTIVE DATA. ( review of the system, the nurse findings )
• Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
• Differential Diagnoses (list a minimum of 5 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Please note that you can make up information to complete the SOAP note, also the diagnostics tests and differential diagnosis(5 ) must be supported with sources

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Solution

Episodic/Focused SOAP Note

Patient information

Patient Initials: G.H     Age: 42-Year-old              Gender: Male                 Race: Caucasian

S:

CC: lower back pain

HPI: G.H, a 42-year-old Caucasian man, presented to the clinic with a complaint of lower back pain. He claimed that he has been experiencing this sort of discomfort for the past month, with the pain sometimes radiating on his left leg. The patient denies any history of falls or other injuries, as well as any other medical disorders outside arthritis.

Location: back and radiates to his left leg

Onset: one month ago

Character: began out moderate with some slight cramping, but worsened over the morning upon waking up.

Associated signs and symptoms:  burning sensation, numbness and tingling in left foot

Timing: comes and goes

Exacerbating/ relieving factors:  laying down assist ease some of the discomfort, whereas sitting, standing, and walking aggravate it.

Severity:  3/10 pain scale at rest, and a 9/10 when he stands.

Current Medications:

Oxycodone 5/325 mg taken after every 4 hours as appropriate for pain/arthritis

Zestril 20mg Q AM

Allergies: NKDA

PMHx: up to date on immunizations; received a flu shot in May 2020, and last tetanus shot in October 2020. HTN, Arthritis in 2017, disputed any history of injury or falls

Soc Hx: G.H works as a teacher at a neighboring elementary school. He is married to a single wife. The client has two children and is sexually active. He denies smoking but admits to drinking beer on occasion. He rarely takes part in sporting activities. G.H stated that he had been wearing a seat belt when driving.

Fam Hx: Father (75 year-old) with hx of HTN, Mother (64-year-old) with hx of breast cancer.

ROS:

General: denies fever, chills and weight loss.

HEENT: denies visual loss (Last eye exam 2020), denies hearing loss, nasal congestion, and difficulty swallowing.

SKIN: No rash or itching.

CV: No murmur, regular rhythm

RESP: Resp: denies cough, and dyspnea.

GI: no palpable masses

GU: Denies burning in urination

Neuro: denies headache, syncope, ataxia, numbness in the extremities.

Msk: admitted having a history of arthritis since 2019. Reported back pain radiating down his left leg

Hematologic: No anemia, bleeding or bruising.

Lymph: Denies enlarged nodes

Psyn: No history of depression or anxiety.

Allergies: seasonal allergies

O.

Physical exam:

General: alert, and oriented. Appear well nourished.

VS: T 97.8., pulse 82, RR 18, Wt. 247lb, height, 5’10, BMI 35, BP 170/85

Skin: warm and dry. No rashes

HEENT: no abnormality noted.

Lungs are clear.

CV: S1S2 present

Abdomen: There is no distention and no discomfort on palpation. Bowel sounds can be heard in all four quadrants.

Genital/Rectal: Penis and testicles without lesions. No inguinal hernias are present.

Msk: no edema.  Low back pain and mobility limitations in left leg noted.

Skin/Hair/Nails: Normal color for ethnicity and turgor.

Diagnostic results:

• CMP, X-rays; to determine spinal alignment and to identify fractures, tumors, and other abnormalities (Braunstein et al., 2020).
• CT scans for image of the spine; to detect abnormalities such as fractures, infections and tumors
• MRI for evaluation of herniated discs, disc instability, tumors, and nerve/nerve root irritation (Khan et al.,2021). Result not yet out.

DIFFERENTIAL DIAGNOSES:

Osteoarthritis

Osteoarthritis is characterized by the deterioration of the articular cartilage that covers the ends of the bones in synovial joints. It’s often diagnosed in individuals above the age of 50 (Hunter & Bierma-Zeinstra, 2019). Pain is frequently felt in the lower back and is often bilateral. Other symptoms are numbness and tingling, as well as asymmetric reflexes.

Lumbar Stenosis

Lumbar stenosis is characterized by pain during walking or standing upright that appears to begin in the buttocks and may radiate down the legs. Sitting or leaning forward may bring pain relief. Pain may be intensified by prolonged standing, walking, or back hyperextension (Bochicchio et al., 2021).

Low back strain

Because the lower back supports the weight of the upper body and is subjected to mobility, twisting, and bending, muscle strains and sprain are common. This is most common in people between the ages of 20 and 40, and it begins after an inciting incident and causes acute low back pain. Low back strain is defined by low back discomfort that may extend into the buttocks but does not influence the legs, muscle spasms with or without movement, and pain that lasts for 10-14 days (Patel et al., 2018).

Herniated intervertebral disc

A herniated disk is a disorder that can develop anywhere along spine, but it more common in the lower back. This type of injury is most common in people aged of 30 to 50, and it causes postural impairments in the patient. It is also one of the most prevalent causes of lower back and leg pain (Cosamalón-Gan et al., 2021).

 Spinal compression fracture

Spinal compression fractures occur as a result of an accident, most often a fall onto the buttocks, or compression from regular tasks. It is distinguished by progressive back pain, inability to bend, and kyphosis (Lee et al., 2020).

References

Bochicchio, M., Aicale, R., Romeo, R., Nardi, P. V., & Maffulli, N. (2021). Mini-invasive bilateral transfacet screw fixation with reconstruction of the neural arch for lumbar stenosis: a two centre case series. The Surgeon.

Cosamalón-Gan, I., Cosamalón-Gan, T., Mattos-Piaggio, G., Villar-Suárez, V., García-Cosamalón, J., & Vega-Álvarez, J. A. (2021). Inflammation in the intervertebral disc herniation. Neurocirugía (English Edition), 32(1), 21-35.

Braunstein, J., Hipp, J. A., Browning, R., Grieco, T. F., & Reitman, C. A. (2020). Analysis of translation and angular motion in loaded and unloaded positions in the lumbar spine. North American Spine Society Journal (NASSJ), 4, 100038.

Lee, G., Han, M. S., Lee, S. K., Moon, B., & Lee, J. K. (2020). Traumatic intradural ruptured lumbar disc with a spinal compression fracture: A case report. Medicine, 99(7).

Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. The Lancet, 393(10182), 1745-1759.

Khan, A. A., Rodriguez-Collazo, E. R., Lo, E., Raja, A., Yu, S., & Khan, H. A. (2021). Evaluation and treatment of foot drop using nerve transfer techniques. Clinics in Podiatric Medicine and Surgery, 38(1), 83-98.

Meints, S. M., Mawla, I., Napadow, V., Kong, J., Gerber, J., Chan, S. T., … & Edwards, R. R. (2019). The relationship between catastrophizing and altered pain sensitivity in patients with chronic low back pain. Pain, 160(4), 833.

Patel, V. D., Eapen, C., Ceepee, Z., & Kamath, R. (2018). Effect of muscle energy technique with and without strain–counterstrain technique in acute low back pain—A randomized clinical trial. Hong Kong Physiotherapy Journal, 38(01), 41-51.

Shiri, R., Coggon, D., & Falah-Hassani, K. (2018). Exercise for the prevention of low back pain: systematic review and meta-analysis of controlled trials. American journal of epidemiology, 187(5), 1093-1101.

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports, 23(3), 1-10.